Fetal Pain: A Red Herring in the Abortion Debate

By Joyce Arthur (copyright © June 2004; updated May 2005)

published in Free Inquiry magazine, Aug/Sept 2005, pp 44-47.

Does a fetus feel pain in an abortion?

This is not a simple question to answer, despite what then-President Ronald Reagan said in 1984: "When the lives of the unborn are snuffed out, they often feel pain, pain that is long and agonizing."[1] Anti-choice leaders claim that even 8-week old fetuses can feel pain because they react to touch and will pull away from invasive stimuli.[2] The infamous anti-abortion film The Silent Scream from the mid-1980's depicts an ultrasound of a "painful" 12-week abortion, but this film has been dismissed as propaganda by medical experts, who say it is "riddled with scientific, medical, and legal inaccuracies, as well as misleading statements and exaggerations."[3]

This article reviews the scientific evidence related to fetal pain, then looks at the philosophical and psychological aspects of pain. In short, the evidence indicates that fetuses do not feel pain until after the start of the third trimester—and even that evidence remains uncertain because it's impossible to know for sure that fetuses consciously experience pain in the same way that a person does. Regardless, since virtually no abortions occur during the third trimester, it means anti-choicers are raising the issue of fetal pain as a political ploy—it's another possible way for them to restrict abortion. If a woman can be persuaded that an abortion will cause pain to her fetus, she might decide against having one. And if society can be convinced that fetuses feel pain, it might be easier to pass restrictions against abortion.

There is no direct scientific evidence that late-term fetuses feel pain, but we can infer they do based on indirect observations that newborn premature babies appear to feel pain. In 1987, an influential paper by a leading British expert on pain, Dr. K.J.S. Anand, helped persuade the medical community that premature babies feel pain.[4] Prior to that, newborn babies needing surgery usually received minimal anesthesia. Anand demonstrated that painful stimuli to premature babies resulted in hormonal and other physiological stress responses, including increased blood pressure, heart rate, and respiratory rate. He also showed that premature babies given pain medication for surgery had lower complication and death rates than babies that went without.

Both findings indicated that newborn premature babies likely experience some degree of pain (and therefore full-term newborns as well). Some researchers dispute this, however, since the stress response to pain stimuli is not a sure indication of a conscious perception of pain.[5] Regardless, it has since become normal practice to provide pain medication to babies during surgery.

What of the claim by anti-choicers that even very early fetuses can feel pain? In fetal development, most major organs exist in rudimentary form by about 8 to 9 weeks. It takes several months for these organs to grow in size, complexity, and organization to the point they can function. For example, the myelin sheath—the insulating cover on nerve pathways that is required for efficient conduction of pain signals—does not begin forming around nervous system cells (neurons) in the spinal cord until about 24 weeks, and not till after birth in most of the cerebral cortex.[6],[7],[8] Although sporadic brain waves can be detected by about 21 weeks gestation, genuine continuous brain waves do not begin until about 28 weeks,[9] indicating that the nerve circuits needed to carry pain impulses to the brain are not connected till then.

Anti-choicers believe early fetuses feel pain because 8 week-old fetuses already have some peripheral nerve endings that are connected to the spinal cord, allowing them to react to touch and other stimuli. However, this is a simple reflex response that has no conscious awareness associated with it, such as when your lower leg jerks up when your knee is tapped. There is no experience of pain because the nerve circuit is not interacting with the brain. An analogy might be putting a light bulb in a socket and flipping the switch when there are no electrical wires connecting the two, and therefore no current either. Put another way, there is no necessary connection between fetal movement and mental awareness, as we know from the famous example of headless running chickens.

Here’s a brief description of how pain impulses are transmitted through the body and brain. Nerve endings in the skin are the most common point of entry for a pain stimulus. From there, the pain impulse connects—or "synapses"—through the spinal cord, up to the brain stem at the base of the skull, and into the thalamus. The thalamus acts as a switchboard—it receives input signals from the body and transmits them to various parts of the brain. Pain signals from the thalamus go to the cerebral cortex—the thinking and feeling part of the brain. A highly-developed cortex is required to perceive pain signals. Activity at the nerve endings, spinal cord, or thalamus is not enough. At 13 weeks gestation, the brain stem and thalamus are not functional, anyway. Working connections between the thalamus and the higher cortex do not begin to form until about 20 to 26 weeks, with significant development of neuronal activity continuing after birth.[10]

Pain expert Dr. K.J.S. Anand believes the threshold for fetal pain is 20 weeks and possibly as early as 16 weeks. However, contrary to other researchers, he discounts the importance of subjective conscious perception in the experience of pain.[11] He also claims that fetuses may feel pain even more intensely than full-term newborns.[12] Anti-choicers have misinterpreted at least some of the evidence for this, however.[13],[14] For example, they cite Anand's finding that the stress response of premature babies is 3 to 5 times greater than for adults who undergo similar types of surgery—but that's simply because the adults received pain medication and the premature babies did not![15]

The main reason that Anand says premature babies experience more intense pain than full-term newborns relates to the pain inhibitory system—the body's natural pain-relieving ability. Anand claims this system is not functional until at least 32 weeks gestation, and therefore, fetuses between 20 and 32 weeks will experience more pain than full-term infants.[16] The pain inhibitory system allows the brain to release its own morphine-like hormones (endorphins), which dampen or halt the pain experienced during trauma. This may occur, for example, when a person is attacked by a wild animal or injured on the front lines of a war, and it also accounts for the "runner's high." However, morphine-like hormones generally take at least 3 minutes and up to 20 minutes to kick in after the initial onset of trauma because they are transported through the blood.[17],[18] This might be useful for premature babies undergoing surgery without anesthesia, but would be of no benefit to aborted fetuses because they die quickly.

Besides, the body's pain inhibitory system could be at least partly functional earlier in gestation. Researchers have found that endorphins are released by 20-week fetuses during invasive procedures like blood transfusions.[19] In addition, direct nerve pathways from the brain stem to the spinal cord can act independently to inhibit pain (by transmitting serotonin), and would likely be active as soon as they are connected,[20] possibly as early as the first trimester.

To sum up, the scientific evidence shows that early fetuses cannot feel pain, and that no pain experience is even possible before 20 weeks gestation. The current consensus of scientists and medical groups (such as Britain's Royal College of Obstetrics and Gynaecology) is that conscious awareness of pain - and therefore the "true" experience of pain - cannot occur in fetuses until at least 26 weeks gestation (if at all).[21]

Let's put this into the context of the abortion debate. In the United States, 88% of all abortions occur in the first 13 weeks of pregnancy, and over 98% are done by 20 weeks. Only 1.4% of abortions occur after 20 weeks, and virtually all occur before the start of the third trimester at 24 weeks.[22]

Therefore, the issue of fetal pain is a political red herring, because there simply is no pain in the vast majority of abortions.

But we aren't quite ready to conclude that even third-trimester fetuses feel pain. We must also grapple with the enigma of what pain is—because it's subjective to a large degree. Officially, pain has been defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage."[23] But the sensation of pain has also been described as "a very complex and individualized experience, similar in its complexity to abstract notions of pleasure, beauty, or intelligence."[24]

The pain experience requires conscious interpretation by the brain—it is a complex interplay between thinking, emotion, and sensation. In fact, the intensity of a pain signal is not related to the intensity of its perception. Emotions like anxiety and fear can greatly increase one's perception of pain, while a person who is relaxed and confident may not feel much pain at all in the same situation. Anthropologists have observed cultures in which women show virtually no signs of distress during childbirth. Pain can also be reduced or eliminated with a placebo, a fake drug that the recipient believes is real. A person who suffers a sudden trauma, such as a gunshot wound, may not have any immediate pain or at least may not remember it. People can be hypnotized into not feeling pain, and unconscious people are generally not aware of painful stimuli at all.[25] So if the body is producing a pain signal from tissue damage, but the person cannot consciously feel or remember the pain, is that a true experience of pain? Indeed, the degree of discomfort or trauma caused by a pain signal is directly related to the anticipation of pain, its duration, understanding of its cause and consequences, the memory of pain, and its lingering traumatic effects, as well as various personal and cultural factors.

In the quick death of a fetus being aborted, these elements of pain aren't likely to come into play, thus presumably reducing the overall significance of any pain felt. Besides, many researchers are unsure when - or even if - a fetus achieves enough consciousness to experience pain at all. Some scientists note that because of the emotional and cognitive elements of pain, and the fact that fetal brains are far from fully developed, it can't be known whether even near-term fetuses experience "true" pain. For example, one researcher argues that conscious awareness requires interaction with the outside world, with social development and language playing crucial roles in the development of self-consciousness. The protected environment of the womb - warm, wet, dark, and buoyant - is a vastly different world from the intense tactile stimulations of life on the outside. The fetus has nothing to gain by being alert and sensate inside the womb, since this would waste energy.[26] In fact, a recent study suggests that fetuses can't feel anything before or during birth because the placenta and fetal brain secrete natural sedatives and anesthetics to encourage sleep and suppress higher cortical activity. Study author David Mellor concluded that suffering can only occur in the newborn when the onset of breathing oxygenates its tissues.[27]

Some scientific uncertainty remains however, and given the intangible and variable nature of the pain experience, it is impossible to determine for sure whether third-trimetser fetuses being aborted can feel pain or not. Even if they can, we have no way of knowing how their pain experience compares to that of a child or adult. However, such scientific skepticism should not trump our common sense and compassion. If there is a reasonable possibility that third-trimester fetuses can feel pain similar to that of a full-term newborn, we should act ethically to minimize any suffering that might occur during rare, third-trimester abortions.

In 1996, Britain's Royal College of Obstetricians and Gynaecologists recommended that doctors performing abortions after 24 weeks should consider providing drugs to the fetus.[28] This is already common medical practice (in North America at least). For starters, women undergoing third-trimester abortions - all because of severe fetal abnormalities or a serious risk to the health or life of the woman - are typically given enough anesthesia to provide at least some protection to the fetus as well. In fact, a general anesthetic appears to sedate the fetus quite effectively.[29] Pain medication is apparently never administered directly to the fetus, since this approach is fraught with uncertainty and risks. In most if not all cases, abortion providers euthanize a third-trimester fetus beforehand by injecting it with digoxin to stop its heart. Some even do this for abortions after 18 weeks. (Physicians have other medical reasons for giving euthanasia drugs to a larger fetus before an abortion, mainly to reduce the difficulty and risk of the procedure.)

Anti-choicers are trying to pass legislation to force abortion providers to inform the woman about the "pain" her fetus would feel during an abortion of 20 weeks gestation or more, and to give women the option of pain medication for their fetuses. If doctors fail to comply with the Unborn Child Pain Awareness Act,[30] expected to become law later in 2005, they face losing their license, hefty fines, and civil lawsuits. Eighteen states have also introduced their own fetal pain bills, modeled after the federal act.

But we don't need criminal laws to force doctors to practice good medicine if they're already doing it. Besides, the Act's directive is bad medicine. Doctors must act within their expertise and best judgment, using safe and proven procedures. Instead, we have legislators mandating a rarely-used medical technique, with no track record or research on its safety and efficacy for abortion.[31] The decision to give any drug to a fetus is a medical decision that must stay with the doctor and the pregnant woman - she is the patient in an abortion procedure. Injecting the fetus with pain medication, or increasing the woman's anesthesia levels, introduces significant risk factors to the abortion procedure for the woman. Even offering it as an option can cause the woman needless anxiety and guilt over her abortion (which is arguably the primary motivation behind the federal bill). But abortion providers rightly consider the woman's health and welfare to be paramount, and act accordingly.

That leads to another key reason why abortion providers give euthanasia drugs to the fetus—because some women having third-trimester abortions voluntarily express genuine concerns for the welfare of the fetus during the procedure. Such concerns should be anticipated and honored to achieve peace of mind—not just for the woman, but for the medical staff involved.

Shifting our focus to the pregnant woman puts fetal pain into a more meaningful context. What is completely overlooked in the fetal pain issue is the plight of the woman with an unwanted pregnancy. Anti-choicers are troubled by the imaginary pain of an early fetus, but they never think about the real pain of pregnancy and childbirth experienced by the unwilling woman, both physical and emotional. Her pain is prolonged, often severe, and frequently accompanied by significant suffering. Being forced to endure an unwanted pregnancy and childbirth can negatively affect a woman's whole life. Anti-choicers probably overlook the woman's experience because of an underlying assumption that women are supposed to have babies, it's their duty to endure whatever it takes, and they should be naturally willing to sacrifice themselves to be mothers. That assumption is wrong. Pregnancy and motherhood must be the woman's choice.

Consider also the pain and suffering of many unwanted children. Evidence and studies show that, on average, they have a much more difficult and unhappier time throughout their lives compared to wanted children. For example, they are more likely to suffer from abuse and neglect.[32]

Concern over the non-existent pain of early fetuses is misplaced when we know for sure that unwillingly pregnant women and many unwanted children experience long-term pain and distress. If the real moral imperative is to alleviate pain and suffering, the most compassionate choice in the case of unwanted pregnancy may be an abortion. As for abortions after 24 weeks, virtually all are the result of wanted pregnancies gone wrong. A woman's painfully traumatic decision to abort such a pregnancy should not be overshadowed by concerns for the possible pain of her fetus. That's not to say we shouldn't care about the fetus. But we must trust the woman and her doctor to decide what to do, especially since fetal pain in the third trimester is still so poorly understood.

Thanks to my husband Stephen Arthur (M.Sc) for reviewing earlier drafts.

Endnotes

[27] The Australian. February 21, 2005. No womb for debate, unborn can't hear a thing. www.theaustralian.news.com.au/printpage/0,5942,12317964,00.html

[28] Medical Research Council (government body), United Kingdom. August 28, 2001. Report of the MRC Expert Group on Fetal Pain. www.mrc.ac.uk/pm/pdf-fetal.pdf

[30] Brownback, Sam (Senator, R-Ks). Unborn Child Pain Awareness Act. January 24, 2005. Text: www.nrlc.org/abortion/Fetal_Pain/S512005.html (National Right to Life website)

[31] Cooper, Cynthia L. August 16, 2004. 'Fetal Pain' Bill New Item on Anti-Choice Agenda. Women's e News. www.womensenews.org/article.cfm/dyn/aid/1951